Adolescent women in South Africa face disproportionate HIV acquisition. In this context, evidence remains mixed on whether sexual self-efficacy (SSE)- one’s perceived control in decision-making regarding safe sex, predicts consistent condom use (CCU). Using cross-sectional survey data from 830 adolescent men and women aged 14-19 living in Soweto, South Africa, this thesis conducted gender-based analyses to examine determinants of high-SSE (study-alpha=0.75) and the association between high-SSE and CCU. Results revealed women have higher SSE than men. High-SSE was associated with CCU use for men, but not women. For women, high-SSE was associated with having an adult in the home, and no history of physical violence. Moreover, lower depressive symptomology among women was more predictive of CCU than SSE, indicating that gender-targeted HIV prevention interventions must move beyond individual-level determinants of behaviour to address socio-structural and relational factors influencing syndemic HIV risk among adolescent women in South Africa.

This project sought to interrogate the institution of prenatal care in East Vancouver through the lived experiences of working class and historically marginalized women. Prenatal care in British Columbia is a complex of institutional policies and practices. This project focused on prenatal visits between pregnant women and their chosen maternity care provider. Through the stories and experiences of nine research participants, this project affords insight into how the work of prenatal care might be improved to better the experiences and health outcomes for working class and historically marginalized women and their newborns. This could include integrating more substantive ways of centering women in the institution of prenatal care and recruiting women as active participants, such as the use of group care and lay health care workers. Pregnancy is a time of great change for working class and historically marginalized women, attempts to reduce social inequity can start with the institutions that provide women care throughout pregnancy.

Our population is aging, and life expectancies are increasing globally. One strategy to promote healthy aging is by creating environments that support physical activity. Using a natural experiment study design, this dissertation takes a mixed-methods approach to capture the impacts of a built environment intervention aimed to increase active transportation among community-dwelling older adults. We captured location-specific travel and physical activity using accelerometers and GPS monitors one year before and after the Comox-Helmcken Greenway was developed, and measured change in weekly transportation-related activity, specific activity along the Greenway, and activity along a comparison corridor. Secondly, we interviewed a subset of these older adults to capture their perceptions of the Greenway. We found no change in weekly physical activity levels, but a decrease in the number of trips along the Greenway. Our interview data suggests this may result from confusion of messaging, the steep slope, and a lack of destinations.

Self-efficacy (SE) has been regarded the strongest cognitive determinant of cigarette use during pregnancy, but has yet to be assessed in pregnant women who use alternative modes of nicotine, including electronic nicotine delivery systems (ENDS). Knowing that nicotine is harmful to the fetus, more research on SE in pregnant ENDS users is warranted. Using data from the BC Healthy Connections Project, the purpose of this research was to identify differences in SE between pregnant: cigarette users; ENDS users; combination users (ENDS and cigarettes); and abstainers (no tobacco or nicotine). The relationship between SE and mode of nicotine was examined using multiple linear regression. Due to small sample sizes, ENDS and combination users were collapsed (ENDS/combination users). SE was significantly higher in ENDS/combination users compared to abstainers. No other significant group differences emerged. Results from this research can be used to tailor interventions aimed at reducing fetal exposure to nicotine.

Introduction: In 2012, the Supreme Court of Canada (SCC) expanded the reach of criminal liability for HIV non-disclosure in Canada when it ruled that people living with HIV (PLWH) who do not disclose their HIV status before sex that has a “realistic possibility” of HIV transmission could face criminal charges, suggesting that condom-protected vaginal sex with a low HIV viral load would incur no legal obligation to disclose. This thesis sought to identify the prevalence and correlates of facing a legal obligation to disclose, and to investigate awareness, understanding and perceived healthcare impacts of the 2012 SCC ruling among the diversity of women living with HIV (WLWH) in Canada, involving WLWH as key research partners.Methods: Quantitative data from men and women enrolled in a cohort of PLWH who use illicit drugs in Vancouver (ACCESS), and women enrolled in a community-collaborative cohort of WLWH in British Columbia, Ontario, and Quebec (CHIWOS), were used to meet the objectives of this thesis. Novel community-driven questions assessing awareness, understanding and perceived impacts of HIV non-disclosure case law were incorporated into data collection instruments of both cohorts. Results: Among ACCESS participants who use injection drugs (n=176), WLWH were more likely to face a legal obligation to disclose compared to men in the wake of the 2012 SCC ruling. Among female ACCESS (n=98) and CHIWOS (n=584) participants, awareness of the 2012 SCC ruling (44% and 74%, respectively) and understanding of the conditions under which PLWH may face a legal obligation to disclose (17% and 35%, respectively) were suboptimal. Although most participants were engaged in HIV treatment and care, discussions about HIV disclosure and the law were lacking in healthcare settings, despite participants expressing a willingness and desire to engage in discussions of this nature with providers. Most participants believed that HIV non-disclosure case law might limit the type of information WLWH would share with providers.Discussion: This thesis identified an urgent need to disseminate information about HIV non-disclosure and the law in community and healthcare settings, to ensure WLWH have fundamental information to avoid prosecution and to optimise their health and rights in the current legal climate.

Background: Antiretroviral therapy (ART) and ambitious treatment strategies such as Treatment as Prevention (TASP) and 90-90-90 have reduced HIV-related morbidity and mortality among people living with HIV (PLWH), and substantially decreased the likelihood of transmission of the virus to others. The benefits of ART are not felt equally among all PLWH, as PLWH may not be able to maintain ART adherence. This study examines gender differences in ART adherence and the sociostructural and psychosocial factors associated with such differences in British Columbia, Canada. Methods: Quantitative analyses assessed optimal ART adherence by gender, longitudinally and cross-sectionally, using bivariate, multivariate analyses, as well as structural equation modelling. All analyses used data collected from 2000 onward by the BC Centre for Excellence in HIV/AIDS from BC, Canada, with adherence measured using pharmacy refill compliance data. Findings: Gender-based disparities were evident in ART adherence in BC, with a significantly lower proportion of women attaining optimal (≥95%) adherence relative to men (57.0% versus 77.1; p<0.001) regardless of subgroup. Women also experienced far greater sociostructural and psychosocial disparity than men, however food insecurity was the only variable examined that was independently associated with suboptimal adherence among women (adjusted odds ratio [AOR]: 0.364; 95% confidence interval [CI]: 0.181 to 0.734). Psychosocial variables exhibited different effects and interactions for men and women, however, they explained only a low proportion of the variability observed in ART adherence (1.6% and 3.7%, respectively). Disclosure worries was the only psychosocial variable to affect women’s adherence (standardized regression weight [r]: -0.192; p=0.015). Personalized stigma (r: 0.299; p<0.001) and internalized stigma (r: 0.321; p<0.001), however, did have a significant explanatory affect on depression experienced by women. Discussion: Gender-based disparities must be addressed if women living with HIV are to attain optimal health and if we are to achieve the goals of 90-90-90. Addressing aspects of poverty and the greater adversity that women face in this regard would result in a more salient improvement to ART adherence than interventions addressing stigma.

Homeless mothers represent an extremely vulnerable population. Research consistently revealed that they experience poor quality of life (QoL) and increased depression. Evidence also indicated that increased QoL is associated with improvements in depression. Whether the effect of parenting status on depression is mediated by QoL is unclear. This study, therefore, examined how parenting status affects depression among homeless women, through subjective quality of life (SQoL). This secondary analysis drew from the 325 chronically homeless women who completed the At Home/Chez Soi Study baseline questionnaire. Associations were examined using bivariate analyses and mediation analyses were performed using bootstrapped regression models. SQoL explained the association between parenting and depression; leisure accounted for the largest proportion (27%) of the variance on depression. The findings highlighted the importance of providing supports to homeless mothers, so as to improve their SQoL and depression. Specifically, findings suggested that leisure could partially improve depression among homeless mothers.

Although evidence suggests that depression is one of the leading causes of morbidity and disability in the world, treatment for depression is often unavailable, especially in low and middle-income countries. This gap in treatment has led to momentum to improve and scale-up services through approaches such as task-shifting. These steps, however, must be carefully considered to ensure that such efforts are appropriate, effective and acceptable for populations being served. This dissertation assesses barriers and facilitators to the integration of services for depression in primary care in Vietnam from the perspective of primary care providers (PHPs) by examining sociocultural considerations and individual, organizational and structural factors that might influence the process of service integration. The study has three components. The first, a narrative review, explores considerations for studying depression cross-culturally and the implications for global depression research. The results suggest that although depression is universally experienced, it varies by cultural context, and improved epidemiological methods that account for these cross-cultural variations are needed. The relationship of social determinants of health to depression must also be further explored. The second component, a qualitative study, examined how depression is conceptualized in Vietnam from the perspective of PHPs. Findings indicate that although depression is not widely recognized or seen in primary care, depression in Vietnam is largely understood in psychosocial terms. Along with efforts to improve screening and help-seeking, the introduction of psychosocial depression interventions in primary care is both appropriate and important. The third component used mixed methods to assess barriers and facilitators to the integration of services for depression in primary care. The findings suggest that although PHPs are motivated to build capacity and deliver services for depression for their patients, systemic factors must be addressed to ensure that PHPs are adequately trained and supported to deliver psychosocial interventions. By integrating an approach that examines sociocultural considerations of depression with individual, organizational and structural factors influencing service integration, this study suggests that a balance is both necessary and possible between approaches prioritizing efficient treatment delivery and those emphasizing the need for contextualization and careful sociocultural consideration. A balance of these approaches should be applied when introducing enhanced depression services cross-culturally.

Reproductive behaviors are shaped by a plethora of selective pressures, past and present. On an ecological time scale, reproductive “decisions” are made by balancing life-history trade-offs that are dependent on intrinsic and extrinsic factors, such as resource availability and age. Mathematical models are powerful tools that allow for the systematic investigation of such factors, and to test whether selective forces thought to be responsible for particular traits had been correctly identified. In this thesis, I present a dynamic state variable model for the optimization of reproductive scheduling under a range of family and environmental contexts. Next, I test one of the model’s simplifying assumptions, that sons and daughters cost the same to produce and to raise, via secondary data analysis of two existing data sets. These results are discussed in parallel to the benefits of applying principles of evolutionary ecology to public health problems.

Background: Reducing malaria mortality is a global priority. Uganda has focused its national strategic plan to have by 2010: 85% of children under five receive first-line antimalarials within 24 hours of fever onset and following diagnostic confirmation. In 2004, artemisinin-combination therapies (ACTs) were adopted as first-line treatment for uncomplicated malaria in children older than 4-months. Method: A three-study series investigated caregivers’ malaria related treatment-seeking behaviors for young children to inform future public health initiatives in Uganda’s Butaleja District: a literature review, a household survey, and a multiple case study. In this document, these appear as three manuscripts in Chapters 2-4. Results: While drug delivery improvements have increased ACT usage, these studies concur that initiatives still failed to meet the 2010 national target. Only 21% of children received blood tests, 31.6% received no antimalarials, 31.6% received “appropriate” (only first-line) antimalarials, and 36.8% received subordinate antimalarials. Among subordinates, 5.8% of children were mis-prescribed ACTs and 22.4% received ACTs and subordinate antimalarials. Home management was an important initial treatment source since visits to public facilities were commonly associated with hardships. Caregivers’ knowledge and preference about antimalarials varied with prior experiences and beliefs. The survey evaluated 160 behavioral questions in determining four independent predictors of likelihood that a child would receive an “appropriate” antimalarial: obtaining antimalarials from regulated outlets (OR=14.99); keeping ACT in the home for future use (OR=6.36); reporting they would select ACT given the choice (OR=2.31); and child’s age older than 4 months (OR=5.67). The study further employed the Health Belief Model to identify 10 scales of “Assets” and “Challenges” to guide more precise insights into caregivers’ behaviors. Four “Asset” scales predicted significantly whether a child received an “appropriate” antimalarial: Precursors to Receiving an Appropriate Antimalarial (R2=21%); Episode Management (R2=39%); Caregiver Knowledge (R2=6%); and Professional Assistance with Critical Decision (R2=9%). Similarly, two “Challenge” scales were significant predictors: Lack of Assistance with Critical Decision (R2=9%), and Problems Obtaining a Best Antimalarial (R2=4%).Conclusions: To conform practice to policy, this research sequence highlighted the importance of engaging the full spectrum of stakeholders in public health initiatives to manage malaria, including licensed and unlicensed providers, caregivers and family members.